Identifying Shoulder Pathology with Surgical

Repairs and Replacement of the Shoulder

Dr. Terry Rzepkowski, DPT

Associate Professortrzepkowsk@nova.edu

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Shoulder Objectives

Understanding:

• UE anatomy and musculature

• Mechanisms of injury

• Clinical testing

• Operative procedures

• Non-op Interventions

The ShoulderAnatomy

Clarification of Terms

Shoulder Complex =

Shoulder girdle

(scapula and clavicle)and

Shoulder joint

(scapula and humerus)

Scaption PositionNatural position is scaption: 30

degrees anterior to the Frontal

plane1,2

Clarification of Terms(cont’d)

Shoulder Complex

A. Sternoclavicular joint

B. Acromioclavicular joint

C. Glenohumeral joint

D. Scapulothoracic

articulation

Often imitated, never duplicated

Video

Steering and suspension

Shoulder Girdle

• Term used to discuss activities of the scapula, clavicle, and sternum

• The sternoclavicular (SC) and acromioclavicular (AC) joints allow shoulder girdle motions3-5

– Elevation and depression

– Protraction and retraction

– Upward and downward rotation

– Upward tilt-Reduction of Upward Tilt

Joint Motions Shoulder GirdleA. Elevation-depression

B. Protraction-retraction

C. Upward rotation-downward rotationD. Upward tilt-Reduction of Upward Tilt

D

Sternoclavicular Joint: Motions

Frontal planeElev/Dep

Sagittal planePost Rot

Horizontal planeProT/ReT

Ant/Post axisVertical axis

Acromioclavicular Joint: Osteokinematics

Horizontal plane

adjustments

during scapulothoracic

protraction

Sagittal plane adjustment

during scapulothoracic

elevation

Companion MotionsShoulder Joint and Shoulder Girdle

• Movement of the scapula is accompanied by movements of the glenohumeral joint and vice-versa

• Example: Shoulder flexion is accompanied by upward scapular rotation

• Impairment of one joint will also impair function at the other

Muscular Considerations

• Poor Posture

– Pec Minor tightness

– Biceps (short head) tightness

• Result

– Scapular protraction

– Decrease posterior tilt of scapula

– Decreased S-A space height

• Patient education point

– “Slouching active elevation test”

Scapulohumeral rhythm

• Shoulder Joint

– abduction

– Adduction

– flexion

– extension

– internal rotation

– external rotation

– horizontal abduction

– horizontal adduction

• Shoulder Girdle

– upward rotation

– downward rotation

– elevation/upward rot.

– Depression/downward rot.

– Abduction (protraction)

– adduction (retraction)

– adduction (retraction)

– abduction (protraction)

Active ROM Tests*Performed Bilaterally

• Apley’s Stretch Test

– Touch opposite acromion with hand of affected shoulder (add/IR)

– Reach behind the head and touch opposite shoulder from behind(abd/ER)

– Reach behind back and touch opposite scapula(add/IR)

Appley Scratch Test

• Adduction and Internal rotation: Ask the patient to place their hand behind their back, and instruct them to reach as high up their spine as possible. (T1)

• Abduction and External rotation: Ask the patient to place their hand behind their head and instruct them to reach as far down their spine as possible. (C7)

Appley Scratch Test

Video

Appley Test

The Shoulder Joint

• Also called the glenohumeral joint

– Ball-and-socket diarthrosis between head of humerus and

glenoid cavity of scapula.

– Allows more motion than any other joint

– Is the least stable

– Supported by 2 types of stabilizers:

1. Dynamic skeletal muscles and tendons

2. Static stabilizers of ligaments, labrum

The Shoulder Joint• Shoulder Ligaments

– Coraco-acromial- Causes SA compression often removed

– Coracoclavicular- Holds clavicle to scapular complex

– Acromioclavicular- Stabilizes AC joint

– Coracohumeral- Not commonly traumatized, or compromised

surgically

– Glenohumeral- Anterior dislocation and TSA

• Shoulder Separation: Acromioclavicular Joint

– Shoulder Dislocation: Glenohumeral Joint

Ligament Injuries

Shoulder Separation Shoulder Dislocation

Coracoacromial ligament

G. Coracoacromial

ligament

– Connects coracoid process to acromial process

– Roof over head of the humerus, serves as a protective arch

Shoulder Joint

Impingement Syndrome

• Very common

– Laborers

– Persons who do repetitive overhead motion

– Athletes

• Cause

– “the tendons of the rotator cuff (and subacromial bursa) are crowded, buttressed, or compressed under the Coraco-acromial arch, resulting in mechanical wear, stress, and friction”

Subacromial Space Primary Bony Impingement

• Causes for decreased subacromial space

– Degenerative changes

– Osteophyte formation

• On Acromion process

– Shape of acromion process

• Straight (Type 1)

• Slight hook (Type 2)

• Hooked (Type 3)

– Loss of scapular stabilization

Supraspinatus

• Compression, centering of humeral head

• Peak activity = 30-60° elevation

Abduction at Glenohumeral JointInitiates abduction

Active for first 110 degrees of abduction

Active 90-180 degrees of abduction

Superior dislocating component neutralized by infraspinatus, subscapularis, and teres minor

Roll/slide mechanics

Impingement: Roll-Slide Kinematics

“Roll” created by abduction not countered with “Slide” action

• Primary contributor = osseous adaptation

– Humeral retroversion

– Repetitive torsional stress (horizontal abduction and external rotation)

– Professional pitchers

– Average increase = 17° side to side

– Crockett, AJSM ’02

Adaptive Changes

“Glenohumeral Internal Rotation Deficit”(G.I.R.D.)

Rotator Cuff Injuries

• “Internal Impingement”• Impingement of RC on

posterior-superior glenoid rim and labrum

• Extreme shoulder abduction with ER

• Contributing factors• Excessive anterior translation

• Excessive ER

• Excessive humeral retroversion

• Pain at late cocking phase

Effects of Primary and Secondary Rotator Cuff Impingement

• Scapular Weakness– Affects humeral head stabilization– “functional scapular instability”

• Affects– Scapular position during activities that causes

» “relative decrease in subacromial space”• This can cause secondary impingement

– Weak scapular muscles (serratus anterior, traps (3), rhomboid) with postural imbalance of levator and pec minor

Impingement

Possible mechanisms

Weak or inflexible rotator cuff

Small anatomical space

GH ABD + ROT

Scapular positioning and weakness

2 types of Impingement

• Primary

• Anatomical cause of rotator cuff injury

– Mechanical compression of r/c tendons

• Primarily which one?

• Secondary

• Kinesiological cause of injury

– Related to GH instability that creates reduced subacromial space

• Causes of GH instability?

MRI of RTC Impingement

ROTATOR CUFF

TENDON

Impinged Tissues

Tests for RTC Impingement

• Impingement tests:

• Neer (Coracoacromial arch)

• Hawkins Kennedy (Sub-acromial region)

• Cross Over (AC region)

• *Literature indicates that these tests are better for ruling out a condition if negative than ruling in if positive4

Requirements of All impingement tests

1. Stabilize the scapula

2. Full internal rotation

3. Taken to the end of capsular motion with overpressure

4. Note area of discomfort, is it correlative to the referral area for pain.

Neer impingement Test

RTC impingement test Coracoacromial arch

Hawkins Kennedy Test

RTC impingement Test Subacromial

Cross Over Impingement Test

RTC impingement testAcromioclavicular

Video

Impingement tests

MRI of RTC Impingement

ROTATOR CUFF

TENDON

Sub Acromial Decompression (SAD)

• Impingement (anatomical, and bio-mechanical), RTC Tendonitis, Sub acromial bursitis that is unresponsive to conservative treatment.

• The operation aims to increase the size of the subacromial area and reduce the pressure on the tendon. It involves cutting the ligament and shaving away the bone spur on the acromion bone.

Sub Acromial Decompression (SAD)• Also commonly performed preceding arthroscopic

rotator cuff repair

Video

SAD

BREAK!!

Clavicular Ligaments

E. Acromioclavicular ligament

– Hold the acromion process to the clavicle and prevents posterior dislocation of the clavicle

F. Coracoclavicular ligament

– Not directly located at the acromioclavicular joint

F1. Conoid portion - medial

F2. Trapezoid portion – lateral

AC SeparationCommonly caused by a fall

directly on the "point" of the

shoulder or a direct blow received

in a contact sport resulting in a

piano key deformity

The Bucs quarterback injured on

10/15/17 played on 10/22 and

completed 31 of 43 passes for

385 yards, three touchdowns and

one interception against one of

the best pass defenses in the

NFL—and he did that with no real

passing game, while injured, on

the road.

AC separation imaging

X-Ray is the best way to

image this, MRI is actually

harder to visually

appreciate due to the

narrow field of reference

Glenohumeral Joint Instability and Dislocation

• Anterior Dislocation

• Occurs with arm abducted, extended, ext rot (FOOSH)

• Occurs more often in men

• Occurs much more commonly than posterior

Glenohumeral Ligaments (B)

• Reinforces anterior portion of the capsule

• Not well-defined

– Superior glenohumeral ligament

– Middle glenohumeral ligament

– Inferior glenohumeral ligament

• Actually pleated folds of the capsule

The Shoulder Joint

• Socket of the Shoulder Joint

– Glenoid labrum

• Deepens socket of glenoid cavity

• Fibrous cartilage lining

• Extends past the bone

• Processes of the Shoulder Joint

– Acromion (clavicle) and coracoid process (scapula)

• Project laterally, superior to the humerus

• Help stabilize the joint

• Patient is in pain

• There is loss of the normal contour of the shoulder with a square appearance. Loss of the contour of the shoulder may appear as a step

• Anterior bulge of head of humerusmay be visible or palpable

• A gap can be palpated above the dislocated head of the humerus

• Holds the injured limb with other hand close to the trunk (carry angle)

• The shoulder is abducted and the elbow is kept flexed

X Ray anterior Dislocation of Shoulder

Anterior Shoulder dislocation•Hill Sach’s Lesion

•Can cause neurological symptoms even once reduced

Hill Sach’s imaging

GH Joint Dislocations Cont……….

• Bankart Lesions

• Occurs and classified when force of dislocation great enough to completely dislocate from the glenoid thus tearing the labrum

• “an avulsion of the capsule and labrum off the anterior aspect of the glenoid”

• Results from a traumatic ant. dislocation

Bankart lesions

Hill Sach’s and Bankart

• Hill Sachs: Posterolateral humeral head compression fracture as the humeral head comes to rest against the anterior inferior part of the glenoid.

• Bankart: Detachment of the anterior inferior labrum from the underlying glenoid. It may be labral only ("soft Bankart"), or involve the bony glenoid margin (impaction fracture) and this is called a "bony Bankart".1

Video

Bankart and Hill Sach’s

Subscapularis involvement

Cadaver dissection Relation to GH dislocation

• Anterior dislocation will weaken if not cause tearing and disruption to the subscapularis.

• Positive clinical testing for the subscapularis may indicate previous subluxation/dislocation of the GH joint

Multi-directional Instability(MDI)

• Subluxation in multiple directions

• Sports with repetitive abduction and ER

– Swimmers, gymnasts

• Symptoms

– Sensation of dislocation

– “Directional symptoms”

• Anterior: HAB, 90-90° position

• Posterior: HAD, pushing movements

• Inferior: discomfort carrying heavy objects

Sulcus sign

• Seen in CVA when there is not enough tone to resist gravity.

• Also seen in the unstable MDI shoulder when a traction force is applied.

Video

Piano key and sulcus sign

Special Tests - Instability

• Anterior apprehension sign2

Relocation Test• Following positive apprehension pain is

reduced with posterior humeral head force

Anterior Release/Surprise Test

• Place the pt. in the 90/90 position

• Apply a posterior translator humeral force

• Release quickly

• Pain on rebound is a positive test

Combination of Anterior GH Instability tests can all be done in sitting

Video

GH Dislocation tests

Bankart Lesion Repair

GH Joint Dislocation Cont……

• Hill-Sachs Lesion

• Results from an injury to head of the humerus

• Caused by anterior instability

• The actual ‘lesion’ is a compression “impaction” type fracture to the posterolateral aspect of the humeral head

• Results in “instability "and is not the cause

• Instability can occur in a multi-direction pattern: anteriorly, posteriorly, and inferiorly

Remplissage Procedure.

'Remplissage' is French for 'to fill in'.

Video

Dislocation Repair

Athletic trauma

SLAP Lesions

• Superior Labrum, Anterior to Posterior

• Traumatic

– Fall on outstretched arm

• Atraumatic

– Overhead sports

SLAP Lesions

• SLAP= Superior Labrum Anterior Posterior

• FOOSH mechanism with arm flexed to 90, in closed chain occurs in sports, weight lifting, and also MVA with avoidance pressure on the steering wheel.

Traumatic SLAP Injuries

• Traumatic events, such as falling on an outstretched arm or bracing oneself during a motor vehicle accident, may result in a SLAP lesion due to compression of the superior joint surfaces superimposed with subluxation of the humeral head.

MRI Imaging Case example

Case study MRI and arthroscopic findings

Atraumatic SLAP Lesions

Proposed Mechanisms of Injury• Eccentric loading

– Deceleration• Eccentric contraction of

biceps

• Tension on long head

• Tendon “pulls off” labrum

– E-stim to biceps• Separation from glenoid

• “Peel back” mechanism

– Cocked position• Torsional stress at biceps

anchor

– Pradham, AJSM ‘01• Increased superior labral strain

during late cocking

– Contribution of compressive load? (internal impingement)

Andrews, AJSM ‘85 Burkhart, Arthroscopy ‘98

SLAP Lesions

Classification (Snyder, Arthroscopy ‘90)

• Type I• Superior labral fraying

• Type II• Most common• Biceps anchor detachment from

glenoid

• Type III• Bucket handle tear of labrum• Normal biceps anchor

• Type IV• Bucket handle tear of labrum

that extends into biceps tendon• Detachment of biceps anchor

SLAP Lesions

• SLAP and Instability

• SLAP tear associated with increased G-H translation

• SLAP tear = 6mm increase in anterior translation

Pagnani, JBJS ‘95

Special Tests – SLAP Lesions

• O’Briens Test, great sensitivity not secificity

• Standing, GH joint flexed to

• 90/adducted to 15

• Forearm pronated/humerus IR

• Apply downward force and repeat in supination3

A-P Slide test

• Stabilize the scapula with heel of

the hand on the spine of the

scapula and the fingers over the

coracoid

• Isolate the head of the humerus

sliding anterior and posterior.

• SLAP will produce pain in the

opposite direction due to labral

separation. Bankart will be in the

same direction due to instability.

Special Tests – SLAP Lesions

• Compression / rotation test, good specificity, pain is 180 opposite the compression due to labral separation.

Special Tests – SLAP Lesions

Compression Rotation Test

Photos courtesy of MikeReinold.com

Biceps Load II

The patient is in the supine position with the shoulder in 120

degrees of elevation and full external rotation, while the elbow

is in 90 degrees of flexion, and the forearm in supination. The

patient is then asked to flex the elbow as the clinician

provides resistance.

Diagnostic Properties

Sensitivity: 0.897

Specificity: 0.966

SLAP and Biceps LH• Superior labral tears and detachment of the

Biceps LH

• Labral repair surgery involves re-anchoring or trimming the torn piece of cartilage.

Video

Slap repair

BREAK!!

The Muscles of the RTC

93

Rotator cuff = S.I.T.S.SupraspinatusInfraspinatusTeres MinorSubscapularis

Function of Rotator Cuff

• Large external muscles (e.g., lats, delts) create shear forces

• Rotator cuff provides

– Joint compression

– Tangential restraint (Ant, Post, Sup)

Deltoid produces superior shear force at GH joint.

Subscapularis

• Resists superior shear

• Produces simultaneous internal rotation

Infraspinatus & Teres Minor

• Resists superior shear

• Neutralizes SUBSCAP internal rotation

Summary of Active Arthrokinematics Resisting Shear

Destabilizing Action of Latissimus Dorsi

• LD pulls humerus INF

• SSP resists INF force

• INF & SUBSCAP create compressive force

Overhead Sport Skills

Overhead Mechanics

Complexities of Pitching & Overhead Serving

• Highly skilled

• High angular velocities

• High rotational torques

• High generated forces

• Tremendous flexibility/ROM

• Muscular strength

• Muscular coordination

• Synchronicity of motion

• Force transmission

• Neuromuscular control

• Dynamic stabilization

• Repetitive loading

Extraordinary demands on soft tissue, joints and

growth plates

HIGH INJURY RISK

Goals of Kinetic Chain

• Proximal segments

– Large relative muscle mass

– Primary force / kinetic energy producer

– Accelerate the chain

– Sequentially transfer energy to next distal segment

– Decelerate forces after release

• End result

– Transfer maximum force through distal segment to ball

– Dissipation of forces after release by continuing the chain movement

Functional Importance of Kinetic Chain

• Seamless transfer of energy

• Maximize use of momentum

• Minimize stress to:

– Ligaments

– Dynamic stabilizers (fatigue concerns)

– Joint

Injury-free, unrestricted participation in sport

Not the Goal of

the Kinetic Chain

Rotator Cuff Injuries

• Primary tensile cuff disease

– Undersurface RC injury tear

– Tensile overload due to deceleration

– Pain after ball release

MRI of RTC Tear

ROTATOR CUFF

TENDON

Preferred ERLS Position

“The ERLS is highly specific and

acceptably sensitive for diagnosis of full-

thickness tears, even in the case of an

isolated lesion of the supraspinatus

tendon.”5

External rotation lag sign (ERLS)

Infraspinatus / teres minor

Damage test. Drop arm 1 + 2

For the supraspinatus: 1 is against

gravity, 2 is with light distal tapping

to account for upper trap

compensation.

Video

Drop Arm

Damage test. Empty can

External rotator test

For the External rotators: a resistive test look, for

compensation

Make sure the elbows are bent with shoulders internally

rotated. This is not a deltoid C5 myotome test

Supraspinatus isolation

• If dissymmetry suspected with empty can test, perform supine isolation for external rotators with scapular stabilization, compare bilaterally.

Damage test, Gerber Lift Off

subscapularis test

For the subscapularis: likely present with GH dislocation test, but

can be seen without, may be present in overuse (swimmers)

Internal Rotation LAG sign IRLS

For the subscapularis: performed only if Gerber is positive

Video

RTC tests

RTC repair• For tears and/or detachment of the any of the

RTC tendons, open and arthroscopically

• repair surgery involves trimming damaged ends and re-anchoring the torn section of tendon.

Video

Arthroscopic RTC repair

Video

Open RTC repair

What is Regenerative Medicine?

Regenerative medicine (Ortho Biologics) seeks to

decrease pain and improve function by using your

body’s own natural cellular mechanisms to accelerate

healing, reduce pain and inflammation, and potentially

regenerate tissue.

Ortho BiologicsOrtho

Biologics(addresses the

root cause)

Prolotherapy

PRP

Growth factors

BMAC

Stem cell

Not All Procedures are uniform• Differences can include:

• Where the stem cells are harvested from (fat cells more cosmetic uses, Bone marrow more applicable to joints)

• How stem cells, or platelets in PRP are separated from the rest of the harvested tissue

• How PRP or stem cells are delivered to the arthritic joint

• These differences are further complicated by more unknowns. For example, how many stem cells are needed for a particular treatment? And how do we determine if a patient’s own stem cells are competent enough to aid in healing?

Injection Procedures

Video

Type 1 PRP

Video

Type II PRP

RTC repair vs ortho biologicBasic Ex progression

Surgical

• Immobilize for 4-6 wks.

• Sling off for bathing and dressing only

• Ice and meds for pain

• Wks 4-6: Gradual return to AAROM

• Wks. 6-12: Gradual return to strengthening

• After wk. 12: Focus on return to sport/activity

Ortho biologic injection

• Gentle PROM-AROM as tolerated

• No lifting. No sudden lifting, no pushing, no overhead reaching

• Heat prior to ROM, meds for pain

• Day 4-Week 2: Begin scapular exercises

• Wks 3-9: Gradual return to strengthening

• Wk 7: return to sport/activity no restrictions

Regenerative Non Surgical Coverage• What does Insurance pay for?

• Evaluation, diagnostic imaging and reading of findings (ALL)

• Ortho biologic treatments: Worker’s comp and other self-insured companies that are self-funded.

• Major Insurance companies as of yet do not cover treatments, but will pay for any therapy and bracing following treatment.

• Cost Examples vary by condition this is an approximation, actual costs vary depending on pathology

• Ortho biologic injection of labrum and adjacent tendinopathies

• PRP alone $1200

• Amnio fix growth factor alone $800

• Combination PRP and Growth factor $1800

• 3 phase stem cell injection $6950

Xray and MRI for Arthritic shoulder

Total Shoulder Arthroplasty (TSR/TSA)

• Indications

– Degenerative changes in articular surfaces

– Late-stage OA, RA, Traumatic Arthritis

– Cuff-Tear Arthropathy (CTA)

– Osteonecrosis (avascular necrosis) of the head of the humerus

– Goal is to:

• Relieve pain

• Improve shoulder mobility and stability

• Improve functional use for ADL’s

TSA Implant design, materials, fixation• Implant Design- high-density

polyethylene glenoid component (usually all plastic) with a humeral component made of a metal which resembles biomechanical features of human bone

• Fixation- press-fit, bio-ingrowth, cement

• Depends upon surgeon’s preference of design as well as strength and integrity of patient’s bone----?????bone cement

TSA Prosthetic Designs• Unconstrained-stemmed humeral component, used

with intact/strong RC

• Semi-constrained-erosion of the glenoid fossa but still can have rotator cuff repair

• Reversed ball and socket -appropriate for patients with very damaged and irreparable RC

TSA/RSA Surgical Approach

• Anterior Approach-Deltopectoral Incision

• Tenotomy –Release the subscap tendon from its attachment on lesser tuberosity

• Osteotomy of humeral head

• ‘Rebalancing of soft tissues intraoperative lengthening or tightening, particularly the rotator cuff

• Repair/Reattachment of the subscapularis

• Dislocation Precautions: “Reaching hand into back pocket” movement to retrieve wallet (men) and fastening bra from behind (women

TSA and Rev TSA• TSA: involves anatomically replacing the humeral

head and glenoid surfaces

• Rev TSA: involves anatomically reversing the humeral head and glenoid surfaces

Video

TSA

Reversed anatomy and convex-concave rule, Dislocations tend to occur more posterior-inferior

Reverse Implant

Video

Reverse TSA

Questions